Proposal Form

Plan Details

Plan Name Plan No

LIC's Jeevan 733
Lakshya

Proposal Date * UIN

27-03-2025 512N297V03
Agency Code Supervisor Code Branch Code
05894652 1169602 652

Access Id Email Id Mobile No.

2453097107 [email protected] 9059717784
I hereby confirm that the mobile number provided by me, is registered in my own name. By ticking this box, I
hereby authorize Life Insurance Corporation of India to verify the above information and call me back even if I
am registered in the Do not call List of TRAI

* Date of Proposal - Pertains to date when customer verified the proposal. Proposal number is
allotted only after receipt of the full proposal-deposit amount by LIC

Details of plan proposed

Term & PPT Sum Assured Installment Premium GST

18 - 15 ₹ 5,00,000 ₹ 33,291 ₹ 1,498
Total Amount Mode of Payment Date of
₹ 34,789 Yearly Commencement **
27-03-2025
AB/ADDB Req AB/ADDB Sum Assured
ADDB REQUIRED ₹ 5,00,000
Applicable to Police Personnel if LIC's Accident Benefit Rider / LIC's Accidental Death And Disability
Benefit Rider is opted for :
(i). Whether you are engaged in police duty in any police organization other than Yes No
paramilitary force?
If "Yes", (ii). Whether you wish to avail the AB/AD& DB rider while on police duty? Yes No

** Date of Commencement - This date is tentative Date of Commencement , subject to change

based on date of payment and underwriting.

Personal details of the life to be insured

Name
Erram Mahendar
Father's Name Mother's Name
LAXMAN SAROJANA

Gender
Male Female Third Gender
Martial Status Date of birth ABHA number
Married 05-08-1987
Age (in years) Residential Status
38 Years Resident Indian
Do you wish to avail the physical policy document? Yes No

please give EIA no. (e-Insurance Account) if available

Employer-Employee Scheme/KMI/HUF

Whether proposal is under Employer-Employee

No
Scheme/KMI/HUF ?
 Communication details of the life to be insured

Present Address for communication

Address Line 1 Address Line 2
S O,Laxman, 5 110 50, Karimnagar Gangadhara X Road, Upstairs Muthoot
Road,
Address Line 3 City District
Finance Limited, Kurikial, Karim Nagar, Gangadhara X Karim Nagar
Andhra Pradesh Road
State Country Pin Code
Andhra Pradesh India 505445
Permanent Residential Address
Address Line 1 Address Line 2
S O,Laxman, 5 110 50, Karimnagar Gangadhara X Road, Upstairs Muthoot
Road,

Address Line 3 City District

Finance Limited, Kurikial, Karim Nagar, Gangadhara X Karim Nagar
Andhra Pradesh Road
State Country Pin Code
Andhra Pradesh India 505445

KYC Particulars

Are you an It Assessee Yes No

PAN Proof of Identity Age proof submitted

AAKPE0936F ekyc ekyc

If Registered under GST Yes No

Occupation Details

Present Occupation Exact Nature of duties Name of the present Length of service
employer
Service (Central Service TGS 11 Years
Govt. /State Govt. GOVERNMENT 7 Months
/PSU/Reputed
Firms)
Annual income source of income Education Purpose of insurance
Qualification
₹ 13,00,000 Employed Post Graduate or
(Salary) Graduate

Are you employed in the Armed Forces Yes No

 Other Personal Details of the life to be insured

Is your occupation associated with any specific hazard or do you take part in hazardous Yes No
activities or have hobbies that could be dangerous in any way?
Are you Politically Exposed Person (PEP) OR are you a family member or close relative of Yes No
PEP ? (As per RBI guidelines PEPs are the individuals who are or have entrusted with
prominent public functions in a foreign country.)
Have you ever been or are currently being investigated, charge sheeted, prosecuted or Yes No
convicted or having pending charges in respect of any criminal/civil offences in any court
of law in India or abroad ?

Lifestyle Details of the life to be insured

Do you smoke / Yes/No If YES, Quantity If STOPPED, Since

consume or have you consumed and how may months
ever smoked / Duration
consumed the
following

Alcoholic drinks Yes No

Narcotics Yes No

Any other drugs Yes No

Do you smoke/consume Yes No

or have you
smoked/consumed
tobacco in any form (
cigars, cigarettes,
beedis, pan masala etc)
in the past 60 months.
(in sticks /packets/
sachets/gms per day)
 Details of previous policies held / proposals applied of the life to be
insured

a) Is your life now being proposed for another assurance or an application for revival of a Yes No
policy on your life or any other proposal under consideration in any office of Life
Insurance Corporation of India or to any other insurer?
b) Whether proposed simultaneously on the life of spouse and children ? Yes No

Has a proposal ( or an application for revival of a policy) on your life made to any office of the
Corporation or to any other Insurer ever been Accepted with extra or modified terms, Withdrawn,
Deferred, Dropped or Declined?, if yes give proposal number& branch / policy number / Name of
Insurer Yes No

Have you during the past one year returned any policy of the Corporation as the same was not
acceptable to you?, if yes give policy number. Yes No

I hereby declare that I do not have any existing policies in-force or lapsed policies with LIC.

I hereby declare that I do not have any existing policies in force or lapsed policies with other Insurers.
 Medical details of the life to be insured

Are you suffering from or have you ever suffered or undergone investigation in the past or have
you been advised to undergo investigation or treatment for the following ailments
1. Lungs/ Respiratory Disease / Persistent cough, asthma, bronchitis, pneumonia, Yes No
Tuberculosis/, pleurisy / spitting of blood/Covid 19etc
2. Peptic ulcer/colitis, jaundice,Hepatitis, anaemia, piles, dysentery, or any other disease Yes No
of the stomach, liver, spleen, gall bladder or pancreas/ digestive disorder
3.Hypertension, Hypotension, rheumatic fever, pain in chest, breathlessness, palpitation, Yes No
any disease of the heart or arteries?
4. Endocrine disorders such as Diabetes, Goitre, Thyroid etc or have you ever passed Yes No
sugar, albumin, pus or blood in urine
5. Any disease of kidney /prostate or urinary system? Yes No

6. Bone / Joint/ Spine Disease/ Arthritis / varicose veins /any bodily defect or deformity Yes No

7. Any disease of ear, nose, throat or eyes, including defective sight or hearing and Yes No
discharge from the ears
8. Cancer/leukemia/lymphoma/ tumour / cyst/ Any other growth / lumps/ blood disorder Yes No
/enlarged glands
9.Paralysis/epilepsy/ insanity/ tremors, numbness, double vision, dizzy or fainting spells/ Yes No
head Injury / insomnia/ nervous breakdown / Mental Disorder (Depression/ Anxiety, etc.).
/ any other disease of the brain or the nervous system
10. Chronic infections- Skin Disease/ skin eruption/ Leprosy / ,filariasis, gonorrhoea, Yes No
syphilis or any other venereal disease or AIDS&HIV related condition
11. Hernia/hydrocele, varicocele, fistula Yes No

12. Any other disease ? Yes No

 Medical History of the life to be insured

Please state exact height and weight ( without shoes)

Height (in cms) Weight (in Kgs)
170 69

During the last five years did you consult a Medical Practitioner for any Yes No
ailment requiring treatment for more than a week ?
Have you ever been admitted to any hospital or nursing home for general Yes No
check up, observation, treatment or operation?
Have you remained absent from place of work on grounds of health during the Yes No
last 5 years ?
 Family History

(Please mention specifically if suffering from or died of heart disease, stroke, high blood pressure,
diabetes mellitus, cancer, kidney disease or any hereditary disorders, Insanity, or any contagious
diseases such as tuberculosis ,hepatitis, AIDS / HIV etc)

Relationship Living/Dead Present age State of Age of Death Cause of

Health Death

Father Living 59 Good NA NA

Mother Living 56 Good NA NA

Spouse Living 36 Good NA NA

Son Living 11 Good NA NA

Daughter Living 09 Good NA NA

 Bank details of the life to be insured

Your bank account type Savings Current

Account Number IFSC Code Bank Name

62299208246 SBIN0020142 STATE BANK OF INDIA

Nach Details
Your bank account type Savings Current

Account Number IFSC Code Bank Name

62299208246 SBIN0020142 STATE BANK OF INDIA

Settlement Option

Do you Wish to avail Option for Maturity Benefit in installments Yes No

Do you Wish to avail Option for Death Benefit in installments Yes No

Nomination Details

Particulars of Nomination

SI No. name of Age Relationship Address of

the to the life Nominee Share(%)
Nominee assured
1 ERRAM 36 Wife S O,Laxman, 5 110 100
SRAVANTHI 50, Karimnagar
Road,,Gangadhara X
Road, Upstairs
Muthoot,Gangadhara
X Road,Gangadhara
X Road, 505445

Mobile Email Bank Name Account No

Number IFSC Code

KDCC 200722010029918 TSAB0020007

 Summary of Section 45 of Insurance Laws (Amendment) Act 2015

(1) No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three
years from the date of the policy, i.e., from the date of issuance of the policy or the date of commencement of
risk or the date of revival of the policy or the date of the rider to the policy, whichever is later.
(2) A policy of life insurance may be called in question at any time within three years from the date of issuance
of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to
the policy, whichever is later, on the ground of fraud : Provided that the insurer shall have to communicate in
writing to the insured or the legal representatives or nominees or assignees of the insured the grounds and the
materials on which such decision is based.
Explanation I
For the purpose of this sub section, the expression "fraud" means any of the following acts committed by the
insured or by his agent, with the intent to deceive the insurer or to induce the insurer to issue a life insurance
policy :
(a) The suggestion, as a fact of that which is not true and which the insured does not believe to be true.
(b) The active concealment of a fact by the insured having knowledge or belief of the fact.
(c) Any other act fitted to deceive.
(d) Any such act or omission as the law specially declares to be fraudulent.
Explanation II
Mere silence as to facts likely to affect the assessment of the risk by the insurer is not fraud, unless the
circumstances of the case are such that regard being had to them, it is the duty of the insured or his agent,
keeping silence to speak, or unless his silence is, in itself, equivalent to speak
Notwithstanding anything contained in sub-section (2), no insurer shall repudiate a life insurance policy on the
ground of fraud if the insured can prove that the mis-statement of or suppression of a material fact was true to
the best of his knowledge and belief or that there was no deliberate intension to suppress the fact or that such
mis​statement of or suppression of a material fact are within the knowledge of the insurer: Provided that in case
of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive.
Explanation:
A person who solicits and negotiates a contract of insurance shall be deemed for the purpose of the formation
of the contract, to be agent of the insurer.
(4) A policy of life insurance may be called in question at any time within three years from the date of issuance
of the policy or the sommencement of risk or the date of revival of the policy or the date of the rider to the
policy, whichever is later, on the ground that any statement of or suppression of a fact material to the
expectancy of the life of the insured was incorrectly made in the proposal or other document on the basis of
which the policy was issued or revived or rider issued:
Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or
nominees or assignees of the insured the grounds and materials on which such decision to repudiate the policy
of life insurance is based:
Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a
material fact, and not on ground of fraud, the premiums collected on the policy till the date of repudiation shall
be paid to the insured or the legal representatives or nominees or assignees of the insured within a period of
ninety days from the date of such repudiation.
Explanation:
For the purposes of this sub-section, the mis-statement of or suppression of fact shall not be considered
material unless it has a direct bearing on the risk undertaken by the insurer, the onus is on the insurer to show
that had the insurer been aware of the said fact no life insurance policy would have been issued to the insured.
(5) Nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to
do so, and no policy shall be deemed to be called in question merely because the terms of the policy are
adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.

Summary of Section 41 of Insurance Laws (Amendment) Act 2015

No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out
or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate
of the whole or part of the commission payable or any other rebate of the premium shown on the policy, nor
shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be
allowed in accordance with the published prospectuses or tables of the insurer.
Signature of the life to be
Assured
 Declaration of the life to be insured

I Erram Mahendar the person whose life is herein being proposed to be assured, do hereby declare that the
foregoing statements and answers have been given by me after fully understanding the questions and the
same are true and complete in every particular and that I have not withheld any information and I do hereby
agree and declare that these statements and this declaration shall be the basis of the contract of assurance
between me and the Life Insurance Corporation of India and that if any untrue averment be contained therein
the said contract shall be dealt with as per provisions of Section 45 of the Insurance Act,1938 as amended from
time to time. Not-withstanding the provision of any law, usage, custom or convention for the time being in force
prohibiting any doctor, hospital ,diagnostic center and/or employer, reinsurer/ credit bureau from divulging any
knowledge or information about me concerning my health or employment , occupation, insurance , financial
etc. on the grounds ofprivacy, I , my heirs, executors, administrators and assignees or any other person or
persons, having interest of any kind whatsoever in the policy contract issued to me, hereby agree that such
authority , having such knowledge or information, shall at any time be at liberty to divulge any such knowledge
or information to the Corporation, and the Corporation to divulge the same to any Authorised Organisation /
Institution / Agency / and Governmental / Regulatory Authority for the sole purpose of underwriting /
investigation / risk mitigation / fraud control and/or claim settlement. And I further agree that if after the date of
submission of the proposal but before the issue of First Premium Receipt (i) any change in my occupation or any
adverse circumstances connected with my financial position or the general health of myself or that of any
members of my family occurs or (ii) if a proposal for assurance or an application for revival of a policy on my
life made to any office of the Corporation is withdrawn or dropped, deferred or accepted at an increased
premium or on terms other than as proposed, I shall forthwith intimate the same to the Corporation in writing to
reconsider the terms of acceptance of assurance. Any omission on my part to do so shall render this contract to
be dealt with as per provisions of Section 45 of the Insurance Act, 1938 as amended from time to time. I am
aware that if the information on my Tax Residency is found to be false or untrue or misleading or
misrepresenting, I may be held liable for it. I also undertake to inform the Corporation of any change in my Tax
Residency status. I undertake to inform the Corporation immediately of any changes in KYC documents such as
residence. I also give my consent to obtain and share my data from / with Central KYC Registry respectively and
to receive phone calls , SMS/ E mail from Central KYC registry in this regard. I understand that the Corporation
reserves the right to accept /Postpone/ drop/ decline or offer alternate terms on this proposal for life insurance. I
hereby give my consent to receive phone calls, SMS/whatsapp messages, E mail on the above mentioned
registered number(s)/ E mail address from / on behalf of the Corporation with respect to my life insurance
policy/regarding servicing of insurance policies/ notifying about the status of Claim I also understand that the
premium and benefits under the policy are subject to taxes / duties/ charges in accordance with the laws as
applicable from time to time.
Signature of the Life
to be insured

Name Address Pin Code

Erram Mahendar S O,Laxman, 5 110 50, Karimnagar 505445
Road, Gangadhara X Road, Upstairs
Muthoot Karim Nagar Andhra Pradesh
 Suitability Analysis

Proposer Full Name Date of Birth

Erram Mahendar 05-08-1987

Age Maritial Status Occupation

38 Years Married Service (Central Govt. /State Govt.
/PSU/Reputed Firms)

Address
S O,Laxman, 5 110 50, Karimnagar Road, Gangadhara X Road, Upstairs Muthoot
Gangadhara X Road 505445
2. What is proposer'yearly income from: (if life assured is different from the proposer)
Employment Businees / Profession Other Sources H.U.F. if any

Income of life to be
assured

3. Whether income proof submitted? (if Yes, give details below)

Nature of document Is he/she Income tax Is yes, please provide Income Tax Bracket
for income verification Assessee PAN
Yes AAKPE0936F

4. Previous Policy Details (as per proposal form)

5. Family History (as per proposal form)
Spouse Details
Name Occupation Annual Income
NA NA NA
6. Need Analysis
Total Annual Income
₹ 13,00,000
Outstanding Liablities
Secured Loans Non-Secured Loans

based on his age and income, the maximum insurance that can be granted is:
Age Group Multiple of Avg. Maximum allowable
Annual Income Insurance

7.
Object of Insurance How would you like to pay your premiums
Yearly

Risk Profile Time frame for this invesement

8. Categorization of plans in relation to object of Insurance
Category Risk Profile Plan Name
LIC's Jeevan Lakshya

9. Product Chosen
Plan No Plan Name Term Sum Assured
733 LIC's Jeevan 18 ₹ 5,00,000
Lakshya
Mode Premium
Yearly ₹ 33,291

a) if ULIP is proposed:
1st Year 2nd Year 3rd Year onwards Life cover
charges

Policy Administration Fund Management

Charges Charges

b) if Annuity / Pension is proposed:

Target Annuity per annum Type of Annuity Annuity Amount per Defement
annum Period

Is the total insurance added to the present proposal is reasonable in relation to income
The questions above pertain to your personal condition at the time of appliction to your understanding of the
features of the product for which you are applying. This information will not be used for any other purpose and
will remain confidential.
I Erram Mahendar, having received the informationwith respect to the above, have understood the selection
of product befor into this contract. My plan details are as following:
Plan No Plan Name Term Sum Assured
733 LIC's Jeevan 18 ₹ 5,00,000
Lakshya

Mode Premium
Yearly ₹ 34,789

KYC Details as per E-KYC

Personal Details
Pan No
AAKPE0936F

Name Date of Birth

Erram Mahendar 05-08-1987

Gender
Male
Contact Details
C/o. House/ Bldg. / Apt.

Steert/ Road/ Lane Landmark

S/O,Laxman, 5-110/50, Karimnagar Gangadhara X Road, Upstairs Muthoot
Road,

Area/ Locality/ Sector Pincode

505445

Village/ Town/ City P.O.

Gangadhara X Road

District State
Karim Nagar Andhra Pradesh
 LIC's Jeevan Lakshya (Plan No. 733)

Benefit Illustration

LIC's Jeevan Lakshya (Plan No. 733)

A Par, Non-Linked, Life, Individual Savings Plan
(Unique Identification Number - 512N297V03)

Distribution channel Offline Agency name Agency code

Name of Age of
ERRAM MAHENDAR 37 years Date of illustration 27-03-2025
prospect/policyholder prospect/policyholder
Name of life assured ERRAM MAHENDAR Age of life assured 38 years Benefit UID/Proposal no.
Mode of payment of
Policy term 18 years Premium payment term 15 years Yearly
premium

Basic sum assured Rs. 5,00,000 Sum assured on death6 5,50,000 Instalment premium 32,716.00
(at inception of the policy) Rs. (for base plan)

Bonus type Simple reversionary and final additional bonus

How to read and understand this benefit illustration?

This benefit illustration is intended to show year-wise premiums payable and benefits under the policy, at two assumed rates of interest i.e., 8% p.a. and 4% p.a.

Some benefits are guaranteed and some benefits are variable with returns based on the future performance of your insurer carrying on life insurance business. If your policy
offers guaranteed benefits then these will be clearly marked 'guaranteed' in the illustration table on this page. If your policy offers variable benefits then the illustrations on this
page will show two different rates of assumed future investment returns, of 8% p.a. and 4% p.a. These assumed rates of return are not guaranteed and they are not the upper
or lower limits of what you might get back, as the value of your policy is dependent on a number of factors including future investment performance.

Premium summary
Particular Base plan Riders1 Total instalment premium
Instalment premium without GST 32,716.00 575.00 33,291.00
Instalment premium with GST @ 4.50% (1st year) 34,188.00 601.00 34,789.00
Instalment premium with GST @ 2.25% (2nd year onwards) 33,452.11 587.94 34,040.05
GST rate shall be as applicable from time to time.

Page 1
 LIC's Jeevan Lakshya (Plan No. 733)

(Amount in rupees)
Total benefits (including guaranteed and
Guaranteed benefits non-guaranteed benefits)
Non-guaranteed benefits @ 4% p.a. Non-guaranteed benefits @ 8% p.a.
Death benefit Maturity benefit Death benefit4
Total Total Total Total
Annualize Total maturity maturity death death
Policy income benefit, benefit, benefit, benefit,
d
year (End premium 2 Guarante benefit incl. of incl. of incl. of incl. of
of the ed Maturity Total Total
(cumulati payable Lumpsum final final final final
year) surrender in equal benefit Reversion guarantee Special guarantee Special
ve) payable Surrender Reversion Surrender additional additional additional additional
value d surrender d surrender
instalmen on date of ary bonus surrender benefit ary bonus surrender benefit bonus bonus bonus bonus
value3 value3
ts over maturity (FAB), if (FAB), if (FAB), if (FAB), if
value3 value3
o/s term any, @ any, @ any, @ any, @
after 4% 8% 4% 8%
death5 (6+7+FAB (6+11+FA (5+7+FAB (5+11+FA
) B) ) B)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18)

1 32716 0 850000 550000 0 4000 0 10186 10186 15500 0 10186 10186 0 0 554000 565500

2 65432 19630 800000 550000 0 8000 19630 21806 21806 31000 19630 21806 21806 0 0 558000 581000

3 98148 34352 750000 550000 0 12000 36396 38970 38970 46500 42271 50324 50324 0 0 562000 596500

4 130864 65432 700000 550000 0 16000 68245 55666 68245 62000 76332 71969 76332 0 0 566000 612000

5 163580 81790 650000 550000 0 20000 85306 74561 85306 77500 95415 96509 96509 0 0 570000 627500

6 196296 98148 600000 550000 0 24000 102386 95884 102386 93000 114572 124250 124250 0 0 574000 643000

7 229012 114506 550000 550000 0 28000 119504 119885 119885 108500 133873 155522 155522 0 0 578000 658500

8 261728 138716 500000 550000 0 32000 144527 146820 146820 124000 161234 190676 190676 0 0 582000 674000

9 294444 164889 450000 550000 0 36000 171585 177077 177077 139500 190836 230214 230214 0 0 586000 689500

10 327160 193024 400000 550000 0 40000 200696 210932 210932 155000 222753 274504 274504 0 0 590000 705000

11 359876 223123 350000 550000 0 44000 231892 248853 248853 170500 257104 324171 324171 0 0 594000 720500

12 392592 255185 300000 550000 0 48000 265193 291169 291169 186000 293966 379641 379641 0 0 598000 736000

13 425308 289209 250000 550000 0 52000 300644 338458 338458 201500 333519 441673 441673 0 0 602000 751500

14 458024 325197 200000 550000 0 56000 338290 391249 391249 217000 375932 510952 510952 0 0 606000 767000

15 490740 363148 150000 550000 0 60000 378178 450217 450217 232500 421389 588338 588338 0 0 610000 785000

16 490740 377870 100000 550000 0 64000 395188 487257 487257 248000 444979 645920 645920 0 0 614000 800500

17 490740 441666 50000 550000 0 68000 462066 527710 527710 263500 520716 709251 709251 0 0 618000 818500

18 490740 441666 0 550000 500000 72000 466866 572000 572000 279000 539316 786500 786500 572000 786500 622000 836500

Page 2
 LIC's Jeevan Lakshya (Plan No. 733)

Notes:

The main objective of the illustration is that the client is able to appreciate the features of the products and the flow of the benefit in different circumstances with some level of
quantification.
This illustration is applicable to a standard (from medical, life style and occupation point of view) life.

1. It includes rider(s) premiums in respect of all the rider(s) opted by the proposer/policyholder at inception of the policy.
2. Annualized premium excludes underwriting extra premium, frequency loadings on premiums, the premiums paid towards the riders, if any, and goods & service tax. Refer
sales literature for explanation of terms used in this illustration.
3. Surrender value is higher of guaranteed surrender value (GSV) and special surrender value (SSV). SSV shall be reviewed in line with IRDAI Master Circular on Life
Insurance Products (Ref no.: IRDAI/ACTL/MSTCIR/MISC/89/6/2024 dated 12th June, 2024) and any subsequent circulars issued by IRDAI in this regard. For surrender
value calculation, it is assumed that the bonuses shall vest upon its declaration based on experience of the Corporation under this product, in the manner as per the terms
and conditions of annual valuation results.
4. In any case the total death benefit i.e. the sum of total income benefit and lump sum amount payable on maturity shall not be less than 105% of the total premiums paid
(excluding GST, extra premium and rider premiums, if any).
5. In case of death of the policyholder during the policy term, annual income benefit equal to 10% of basic sum assured shall be payable from the policy anniversary
coinciding with or following the date of death of the life assured, till the policy anniversary prior to the date of maturity. In addition to this, an amount equal to 110% of basic
sum assured (as mentioned in column no. 5) shall be payable on due date of maturity on happening of death in any of the policy years.
6. Lumpsum payable on date of maturity, on happening of death in any of the policy years, is actually payable only at the end of the policy term.
7. The actual allocation to policyholders, out of the surplus emerging from the actuarial investigation, shall be in accordance with provisions in this regard under LIC Act, 1956.

I, ________________________________________ (name), having received

I, ________________________________________ (name), have explained the information with respect to the above, have understood the above statement
the premiums and benefits under the product fully to the prospect/policyholder. before entering into the contract.
Place : Place :
Date : Signature of agent/intermediary/official of the insurer Date : Signature of prospect/policyholder

Page 3